151
|
Neonatal and Paediatric Heart and Renal Outcomes Network: design of a multi-centre retrospective cohort study. Cardiol Young 2019; 29:511-518. [PMID: 31107196 DOI: 10.1017/s1047951119000210] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury is common. In order to improve our understanding of acute kidney injury, we formed the multi-centre Neonatal and Pediatric Heart and Renal Outcomes Network. Our main goals are to describe neonatal kidney injury epidemiology, evaluate variability in diagnosis and management, identify risk factors, investigate the impact of fluid overload, and explore associations with outcomes. METHODS The Neonatal and Pediatric Heart and Renal Outcomes Network collaborative includes representatives from paediatric cardiac critical care, cardiology, nephrology, and cardiac surgery. The collaborative sites and infrastructure are part of the Pediatric Cardiac Critical Care Consortium. An acute kidney injury module was developed and merged into the existing infrastructure. A total of twenty-two participating centres provided data on 100-150 consecutive neonates who underwent cardiac surgery within the first 30 post-natal days. Additional acute kidney injury variables were abstracted by chart review and merged with the corresponding record in the quality improvement database. Exclusion criteria included >1 operation in the 7-day study period, pre-operative renal replacement therapy, pre-operative serum creatinine >1.5 mg/dl, and need for extracorporeal support in the operating room or within 24 hours after the index operation. RESULTS A total of 2240 neonatal patients were enrolled across 22 centres. The incidence of acute kidney injury was 54% (stage 1 = 31%, stage 2 = 13%, and stage 3 = 9%). CONCLUSIONS Neonatal and Pediatric Heart and Renal Outcomes Network represents the largest multi-centre study of neonatal kidney injury. This new network will enhance our understanding of kidney injury and its complications.
Collapse
|
152
|
Mounting Evidence, Improving Understanding: Continuous Renal Replacement Therapy in Critically Ill Children. Pediatr Crit Care Med 2019; 20:379-380. [PMID: 30950988 DOI: 10.1097/pcc.0000000000001822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
153
|
Positive Cumulative Fluid Balance Is Associated With Mortality in Pediatric Acute Respiratory Distress Syndrome in the Setting of Acute Kidney Injury. Pediatr Crit Care Med 2019; 20:323-331. [PMID: 30672838 PMCID: PMC6454886 DOI: 10.1097/pcc.0000000000001845] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES As acute kidney injury and elevated cumulative fluid balance commonly co-occur in pediatric acute respiratory distress syndrome, we aimed to identify risk factors for their development and evaluate their independent relationships with mortality. We hypothesized that acute kidney injury and elevated cumulative fluid balance would be associated with markers of inflammation and that children with elevated cumulative fluid balance and concomitant acute kidney injury would have worse outcomes than other children. DESIGN Prospective observational study using the pediatric Risk, Injury, Failure, Loss, End-Stage acute kidney injury classification. SETTING Five academic PICUs. PATIENTS Two-hundred sixty patients 1 month to 18 years old meeting the Berlin definition of acute respiratory distress syndrome between 2008 and 2014. INTERVENTIONS None. MEASUREMENTS AND RESULTS PICU mortality was 13% (34/260). Relative to survivors, nonsurvivors had greater cumulative fluid balance on day 3 of acute respiratory distress syndrome (+90.1 mL/kg; interquartile range 26.6-161.7 vs +44.9 mL/kg; interquartile range 10.0-111.3; p = 0.008) and also had higher prevalence of acute kidney injury on day 3 of acute respiratory distress syndrome (50% vs 23%; p = 0.001). On stratified analysis, greater cumulative fluid balance on day 3 of acute respiratory distress syndrome was associated with mortality among patients with concomitant acute kidney injury (+111.5 mL/kg for nonsurvivors; interquartile range 82.6-236.8 vs +58.5 mL/kg for survivors; interquartile range 0.9-176.2; p = 0.041) but not among patients without acute kidney injury (p = 0.308). The presence of acute kidney injury on acute respiratory distress syndrome day 3 was associated with mortality among patients with positive cumulative fluid balance (29.1% vs 10.4% mortality; p = 0.001) but not among patients with even or negative cumulative fluid balance (p = 0.430). Day 1 plasma interleukin-6 levels were associated with the development of day 3 positive cumulative fluid balance, day 3 acute kidney injury, and PICU mortality and the association between elevated day 1 interleukin-6 and PICU mortality was partially mediated by the interval development of day 3 positive cumulative fluid balance and day 3 acute kidney injury (p < 0.001). CONCLUSIONS In pediatric acute respiratory distress syndrome, elevated cumulative fluid balance on day 3 of acute respiratory distress syndrome is associated with mortality specifically in patients with concomitant acute kidney injury. Plasma interleukin-6 levels are associated with the development of positive cumulative fluid balance and acute kidney injury, suggesting a potential mechanism by which inflammation might predispose to mortality.
Collapse
|
154
|
Mortality of Critically Ill Children Requiring Continuous Renal Replacement Therapy: Effect of Fluid Overload, Underlying Disease, and Timing of Initiation. Pediatr Crit Care Med 2019; 20:314-322. [PMID: 30431556 DOI: 10.1097/pcc.0000000000001806] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To identify risk factors associated with mortality in critically ill children requiring continuous renal replacement therapy. DESIGN Retrospective observational study based on a prospective registry. SETTING Tertiary and quaternary referral 30-bed PICU. PATIENTS Critically ill children undergoing continuous renal replacement therapy were included in the study. INTERVENTIONS Continuous renal replacement therapy. MEASUREMENTS AND MAIN RESULTS Overall mortality was 36% (n = 58) among the 161 patients treated with continuous renal replacement therapy during the study period and was significantly higher in patients on extracorporeal membrane oxygenation (47.5%, 28 of 59) than in patients not requiring extracorporeal membrane oxygenation (28.4%, 29 of 102; p = 0.022). According to the admission diagnosis, we found the highest mortality in patients with onco-hematologic disease (77.8%) and the lowest in patients with renal disease (5.6%). Based on multivariate logistic regression analysis, the presence of higher severity of illness score at admission (adjusted odds ratio, 1.49; 95% CI, 1.18-1.89; p < 0.001), onco-hematologic disease (odds ratio, 17.10; 95% CI, 4.10-72.17; p < 0.001), fluid overload 10%-20% (odds ratio, 3.83; 95% CI, 1.33-11.07; p = 0.013), greater than 20% (odds ratio, 15.03; 95% CI, 4.03-56.05; p < 0.001), and timing of initiation of continuous renal replacement therapy (odds ratio, 1.01; 95% CI, 1.00-1.01; p = 0.040) were independently associated with mortality. In our population, the odds of dying increases by 1% for every hour of delay in continuous renal replacement therapy initiation from ICU admission. CONCLUSIONS Mortality in children requiring continuous renal replacement therapy remains high and seems to be related to the underlying disease, the severity of illness, and the degree of fluid overload. In critically ill children at high risk for developing acute kidney injury and fluid overload, earlier initiation of continuous renal replacement therapy might result in decreased mortality.
Collapse
|
155
|
Sık G, Demirbuga A, Günhar S, Nisli K, Citak A. Clinical Features and Indications Associated with Mortality in Continuous Renal Replacement Therapy for Pediatric Patients. Indian J Pediatr 2019; 86:360-364. [PMID: 30741388 DOI: 10.1007/s12098-019-02868-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/15/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To identify prognostic factors and indications in patients receiving continuous renal replacement therapy (CRRT) in the pediatric intensive care unit (PICU), and to demonstrate their effect on mortality. METHODS A total of 63 patients admitted between 2011 and 2014 were included in the study. The demographic information, pediatric risk of mortality (PRISM) scores, vasoactive-inotropic score, indication for CRRT, time of starting CRRT, presence of fluid overload, durations of CRRT, and pediatric intensive care unit (PICU) stay were compared between survivors and non-survivors. RESULTS The overall rate of survival was 69,8%. The most common indication for CRRT was fluid overload (31.7%) followed by acute attacks of metabolic diseases (15.9%), and resistant metabolic acidosis (15.9%). The median duration of CRRT was 58 (IQR 24-96) h. The most common CRRT modality was continuous venovenous hemodiafiltration. The CRRT modality was not different between survivors and nonsurvivors. Sepsis, as the diagnosis for admission to intensive care unit was significantly related to decreased survival when compared to acute kidney injury and acute attacks of metabolic diseases. Patients with fluid overload had significantly increased rate of death, CRRT duration, use of mechanical ventilation, and PICU stay. CONCLUSIONS The CRRT, can be effectively used for removal of fluid overload, treatment of acute attacks of metabolic diseases, and other indications in critically ill pediatric patients. It has a positive effect on mortality in high-risk PICU patients. This treatment modality can be used more frequently in pediatric intensive care unit with improved patient outcomes, and should be focused on starting therapy in early stages of fluid overload.
Collapse
Affiliation(s)
- Guntulu Sık
- Pediatric Intensive Care Unit, Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey.
| | - Asuman Demirbuga
- Pediatric Intensive Care Unit, Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Seda Günhar
- Department of Pediatrics, Istanbul University School of Medicine, Istanbul, Turkey
| | - Kemal Nisli
- Department of Pediatrics, Istanbul University School of Medicine, Istanbul, Turkey
| | - Agop Citak
- Pediatric Intensive Care Unit, Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| |
Collapse
|
156
|
Association of Fluid Overload With Clinical Outcomes in Critically Ill Children With Bronchiolitis: Bronquiolitis en la Unidad de Cuidados Intensivos Pediátricos (BRUCIP) Study. Pediatr Crit Care Med 2019; 20:e130-e136. [PMID: 30664037 DOI: 10.1097/pcc.0000000000001841] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Increasing evidence supports the association of fluid overload with adverse outcomes in different diseases. To our knowledge, few studies have examined the impact of fluid balance on clinical outcome in severe bronchiolitis. Our aim was to determine whether fluid overload was associated with adverse clinical outcomes in critically ill children with severe bronchiolitis. DESIGN Descriptive, prospective, multicenter study. SETTING Sixteen Spanish PICUs. PATIENTS Severe acute bronchiolitis who required admission from October 2014 to May 2015 were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Total fluid intake and output were prospectively recorded during PICU assistance. Fluid balance was measured at 24, 48, and 72 hours after PICU admission. A total of 262 patients were enrolled; 54.6% were male. Median age was 1 month (interquartile range, 1-3 mo). Patients had a positive fluid balance during the first 4 days of PICU admission, reaching a neutral balance on day 4. A positive balance at 24 hours in patients admitted to the PICU with severe bronchiolitis was related with longer stay in PICU (p < 0.001), longer hospital stay (p < 0.001), longer duration of mechanical ventilation (p = 0.016), and longer duration of noninvasive ventilation (p = 0.0029). CONCLUSIONS Critically ill patients with severe acute bronchiolitis who present a positive balance in the first 24 hours of PICU admission have poorer clinical outcomes with longer PICU and hospital length of stay and duration of invasive and noninvasive mechanical ventilation.
Collapse
|
157
|
Barbaro R, Fan E. In critically ill children, fluid overload is consistently associated with worse outcomes. BMJ Evid Based Med 2019; 24:41-42. [PMID: 30065112 DOI: 10.1136/bmjebm-2018-111009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Ryan Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Eddy Fan
- Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| |
Collapse
|
158
|
Klinkner DB, Siddiqui S. Renal dysfunction in the pediatric surgical patient: When to intervene. Semin Pediatr Surg 2019; 28:57-60. [PMID: 30824136 DOI: 10.1053/j.sempedsurg.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Renal dysfunction is very common in the pediatric surgical critical care patient, with an estimated incidence of up to 35% in the PICU population. It impacts multiple other organ systems, particularly ventilation, and adds to the morbidity and mortality in children with multisystem organ dysfunction. In this article, we review the definitions and stages of renal failure in the pediatric population, identify which of these are more likely to require renal replacement therapy, and identify the indications for the different types of intervention. In addition, the complications of each form of therapy, along with management options, will be discussed. Finally, we will discuss the immediate and long-term outcomes for pediatric patients from neonates to adolescents.
Collapse
Affiliation(s)
- Denise B Klinkner
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States.
| | - Sabina Siddiqui
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, United States.
| | | |
Collapse
|
159
|
Mottes TA, Goldstein SL, Basu RK. Process based quality improvement using a continuous renal replacement therapy dashboard. BMC Nephrol 2019; 20:17. [PMID: 30634935 PMCID: PMC6330391 DOI: 10.1186/s12882-018-1195-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/26/2018] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND The prevalence of continuous renal replacement therapy (CRRT) utilization in critically ill patients with acute kidney is increasing. In comparison to published and on-going trials attempting to answer questions surrounding the optimal timing of CRRT initiation, anticoagulation, and modality, a paucity of literature describes the quality of the therapy delivered. METHODS We conducted a single-center process improvement project to determine if a methodology to assess the quality of CRRT delivery could lead to improvement in CRRT delivery outcomes. We developed three broad categories of objective CRRT metrics to assess longitudinally, enabling creation of a CRRT Dashboard. Following the objective categories of "filter", "prescription", and "fluid balance" over time allowed us to perform quarterly analyses, target provider based CRRT education, and address variation from our standard of care. From 2012 to 2017, 184 critically ill patients received CRRT. RESULTS We report a mean filter life of 56 + 28.4 h, a 60-h filter life of 62%, and unplanned filter changes of 15%. Compared to a minimum target prescription of 2000 ml/1.73 m2/hour, we report the mean prescribed dose (2300 ml/1.73 m2/hour) and the rate of patients receiving at least the minimum prescription (98%). Finally, using a 10% deviation in the acceptable range of desired daily patient fluid balance, we report 83% CRRT patient days achieving an acceptable stipulated fluid goal. CONCLUSION We report the implementation of a quality dashboard and adopting quality improvement strategies provided a platform for measuring adherence to our institutional standards and the delivery of CRRT, specifically on the process of the care.
Collapse
Affiliation(s)
- Theresa A. Mottes
- Renal Section, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Feigin Building ,1102 Bates Ave, Suite 245, Houston, TX 77030 USA
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229 USA
| | - Rajit K. Basu
- Division of Critical Care Medicine, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA 30322 USA
| |
Collapse
|
160
|
Rizza A, Ricci Z. Fluid and Electrolyte Balance. CONGENIT HEART DIS 2019. [DOI: 10.1007/978-3-319-78423-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
161
|
Ab-normal saline in abnormal kidney function: risks and alternatives. Pediatr Nephrol 2019; 34:1191-1199. [PMID: 29987459 PMCID: PMC6531391 DOI: 10.1007/s00467-018-4008-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
Abstract
Intravenous 0.9% saline has saved countless lives since it was introduced over a century ago. It remains the most widespread crystalloid in both adult and pediatric practice. However, in recent years, evidence of deleterious effects is accruing. These include increased mortality, acute kidney injury (AKI), metabolic acidosis, and coagulopathy. The predominant cause for these sequelae appears to be the excess chloride concentration of 0.9% saline relative to plasma. This has led to development of balanced isotonic solutions such as PlasmaLyte. This review summarizes current evidence for adverse effects of chloride-rich intravenous fluid and considers whether 0.9% saline should still be used in 2018 or abandoned as a historical treatment in favor of balanced crystalloid solutions.
Collapse
|
162
|
Selewski DT, Akcan-Arikan A, Bonachea EM, Gist KM, Goldstein SL, Hanna M, Joseph C, Mahan JD, Nada A, Nathan AT, Reidy K, Staples A, Wintermark P, Boohaker LJ, Griffin R, Askenazi DJ, Guillet R. The impact of fluid balance on outcomes in critically ill near-term/term neonates: a report from the AWAKEN study group. Pediatr Res 2019; 85:79-85. [PMID: 30237572 PMCID: PMC6941736 DOI: 10.1038/s41390-018-0183-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND In sick neonates admitted to the NICU, improper fluid balance can lead to fluid overload. We report the impact of fluid balance in the first postnatal week on outcomes in critically ill near-term/term neonates. METHODS This analysis includes infants ≥36 weeks gestational age from the Assessment of Worldwide Acute Kidney injury Epidemiology in Neonates (AWAKEN) study (N = 645). Fluid balance: percent weight change from birthweight. PRIMARY OUTCOME mechanical ventilation (MV) on postnatal day 7. RESULTS The median peak fluid balance was 1.0% (IQR: -0.5, 4.6) and occurred on postnatal day 3 (IQR: 1, 5). Nine percent required MV at postnatal day 7. Multivariable models showed the peak fluid balance (aOR 1.12, 95%CI 1.08-1.17), lowest fluid balance in 1st postnatal week (aOR 1.14, 95%CI 1.07-1.22), fluid balance on postnatal day 7 (aOR 1.12, 95%CI 1.07-1.17), and negative fluid balance at postnatal day 7 (aOR 0.3, 95%CI 0.16-0.67) were independently associated with MV on postnatal day 7. CONCLUSIONS We describe the impact of fluid balance in critically ill near-term/term neonates over the first postnatal week. Higher peak fluid balance during the first postnatal week and higher fluid balance on postnatal day 7 were independently associated with MV at postnatal day 7.
Collapse
Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | - Ayse Akcan-Arikan
- Sections of Pediatric Critical Care Medicine and Renal, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Elizabeth M. Bonachea
- Department of Pediatrics, The Ohio State University, Section of Neonatology, Nationwide Children’s Hospital, Columbus, OH
| | - Katja M. Gist
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Mina Hanna
- Department Pediatrics, University of Kentucky, Lexington, KY
| | - Catherine Joseph
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - John D. Mahan
- Nationwide Children’s Hospital, The Ohio State University, College of Medicine, Columbus, OH
| | - Arwa Nada
- Department of Pediatrics, Division of Nephrology, LeBonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Amy T. Nathan
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Kimberly Reidy
- Department of Pediatrics, Division of Nephrology, Children’s Hospital at Montefiore/ Albert Einstein College of Medicine, Bronx, NY
| | - Amy Staples
- University of New Mexico, Department of Pediatrics, Albuquerque, NM
| | - Pia Wintermark
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Louis J. Boohaker
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - Russell Griffin
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - David J. Askenazi
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - Ronnie Guillet
- Department of Pediatrics, Division of Neonatology, Golisano Children’s Hospital, University of Rochester, NY
| | | |
Collapse
|
163
|
Watkins LA. Interventions for Pediatric Sepsis and Their Impact on Outcomes: A Brief Review. Healthcare (Basel) 2018; 7:E2. [PMID: 30597866 PMCID: PMC6473772 DOI: 10.3390/healthcare7010002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/13/2018] [Accepted: 12/24/2018] [Indexed: 12/28/2022] Open
Abstract
In the current era, pediatric sepsis remains a public health problem of significant prevalence and impact. With mortality rates practically unchanged over the years, this review hopes to briefly summarize the epidemiology and the current interventions for pediatric sepsis and point towards possible areas of improvement. Most pediatric studies of sepsis are either small, retrospective or observational. Given information technology spreading across country, and a stronger presence of clinical networks, development of multicenter prospective studies over the next decade should enable better treatments for pediatric sepsis, and improved outcomes.
Collapse
Affiliation(s)
- Laura A Watkins
- Department of Pediatrics/Critical Care, School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 667, Rochester, NY 14642, USA.
| |
Collapse
|
164
|
Fayad AII, Buamscha DG, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2018; 12:CD010612. [PMID: 30560582 PMCID: PMC6517263 DOI: 10.1002/14651858.cd010612.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain.This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 11 September 2017. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included five studies enrolling 1084 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early initiation may reduce the risk of death at day 30, although the 95% CI does not rule out an increased risk (5 studies, 1084 participants: RR 0.83, 95% CI 0.61 to 1.13; I2 = 52%; low certainty evidence); and probably reduces the death after 30 days post randomisation (4 studies, 1056 participants: RR 0.92, 95% CI 0.76 to 1.10; I2= 29%; moderate certainty evidence); however in both results the CIs included a reduction and an increase of death. Earlier start may reduce the risk of death or non-recovery kidney function (5 studies, 1076 participants: RR 0.83, 95% CI 0.66 to 1.05; I2= 54%; low certainty evidence). Early strategy may increase the number of patients who were free of RRT after RRT discontinuation (5 studies, 1084 participants: RR 1.13, 95% CI 0.91 to 1.40; I2= 58%; low certainty evidence) and probably slightly increases the recovery of kidney function among survivors who discontinued RRT after day 30 (5 studies, 572 participants: RR 1.03, 95% CI 1.00 to 1.06; I2= 0%; moderate certainty evidence) compared to standard; however the lower limit of CI includes the null effect. Early RRT initiation increased the number of patients who experienced adverse events (4 studies, 899 participants: RR 1.10, 95% CI 1.03 to 1.16; I2 = 0%; high certainty evidence). Compared to standard, earlier RRT start may reduce the number of days in ICU (4 studies, 1056 participants: MD -1.78 days, 95% CI -3.70 to 0.13; I2 = 90%; low certainty evidence), but the CI included benefit and harm. AUTHORS' CONCLUSIONS Based mainly on low quality of evidence identified, early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI, however the 95% CI indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT. Further adequate-powered RCTs using appropriate criteria to define the optimal time of RRT are needed to reduce the imprecision of the results.
Collapse
Affiliation(s)
- Alicia Isabel I Fayad
- Ricardo Gutierrez Children's HospitalPediatric NephrologyInstitute for Clinical Effectiveness and Health PolicyLos Incas Av 4174Buenos AiresArgentina1427
| | - Daniel G Buamscha
- Juan Garrahan Children's HospitalPediatric Critical Care UnitCombate de Los Pozoz Y PichinchaBuenos AiresArgentina
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresArgentinaC1414CPV
| |
Collapse
|
165
|
Hu GH, Duan L, Jiang M, Zhang CL, Duan YY. Wider intraoperative glycemic fluctuation increases risk of acute kidney injury after pediatric cardiac surgery. Ren Fail 2018; 40:611-617. [PMID: 30396300 PMCID: PMC6225368 DOI: 10.1080/0886022x.2018.1532908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The association between poor intraoperative glycemic control and postoperative acute kidney injury (AKI) in adult cardiac surgery has been observed, but data in the pediatrics remain unknown. We performed a hypothesis that intraoperative hyperglycemia and/or wider glycemic fluctuation were associated with the incidence of postoperative AKI in pediatric cardiac surgery. METHODS A retrospective study was performed in pediatrics who underwent cardiac surgery from 2013 to 2016. Perioperative glycemic data up to 48 hours after surgery were collected and analyzed. Patients with AKI were matched 1:1 with patients without AKI by a propensity score. Variables of demographic data, preoperative renal function and glycemic level, perioperative cardiac condition were matched. RESULTS The incidence of AKI was 11.5% (118/1026), with 53.4% (63/118), 30.5% (36/118), and 16.1% (19/118) categorized as AKIN stages I, II, and III, respectively. Children who experienced AKI were younger and cyanotic, underwent more complex surgeries, had higher peak intraoperative glucose levels, wider intraoperative glycemic fluctuation, greater inotropic scores and more transfusions, and poor outcomes (all p < .05). After matching, the AKI group had significantly wider intraoperative glycemic fluctuation (p < .05). Logistic regression showed intraoperative glycemic fluctuation was one of the risk factors for AKI (p = .033) and degree of AKI severity stage increased when the glycemic fluctuation increased (p < .01). CONCLUSIONS Wider intraoperative glycemic fluctuation, but not hyperglycemia, was associated with an increased incidence of postoperative AKI after pediatric cardiac surgery.
Collapse
Affiliation(s)
- Guo-Huang Hu
- a Department of Surgery , The Fourth hospital of Changsha, Hunan Normal University , Changsha , China
| | - Lian Duan
- b Department of Cardiovascular Surgery , Xiangya Hospital, Central South University , Changsha , China
| | - Meng Jiang
- b Department of Cardiovascular Surgery , Xiangya Hospital, Central South University , Changsha , China
| | - Cheng-Liang Zhang
- b Department of Cardiovascular Surgery , Xiangya Hospital, Central South University , Changsha , China
| | - Yan-Ying Duan
- c Department of Occupational and Environmental Health , Public Health School, Central South University , Changsha , China
| |
Collapse
|
166
|
Association of Fluid Overload with Mortality in Critically-ill Mechanically Ventilated Children. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1417-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
167
|
Doi K, Nishida O, Shigematsu T, Sadahiro T, Itami N, Iseki K, Yuzawa Y, Okada H, Koya D, Kiyomoto H, Shibagaki Y, Matsuda K, Kato A, Hayashi T, Ogawa T, Tsukamoto T, Noiri E, Negi S, Kamei K, Kitayama H, Kashihara N, Moriyama T, Terada Y. The Japanese Clinical Practice Guideline for acute kidney injury 2016. RENAL REPLACEMENT THERAPY 2018. [DOI: 10.1186/s41100-018-0177-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
|
168
|
Colbert GB, Szerlip HM. Euvolemia-A critical target in the management of acute kidney injury. Semin Dial 2018; 32:30-34. [PMID: 30412310 DOI: 10.1111/sdi.12753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
It has been clearly established that critically ill patients with sepsis require prompt fluid resuscitation. The optimal amount of fluid and when to taper this resuscitation is less clear. There is a growing evidence that fluid overload leads to acute kidney injury, and increased morbidity and mortality. A clinician's best intentions in resuscitating a patient can lead to too much of a good thing. Currently, there are several bedside tools to aid in determining a patient's response to a fluid challenge as well as in the assessment of the current volume status. Guidelines are not available on the exact rate of fluid overload removal and what medicinal or mechanical modality is most favorable. We discuss our experience and an examination of the literature on the problems with fluid overload, and how a patient may benefit from forced fluid removal.
Collapse
Affiliation(s)
- Gates B Colbert
- Department of Medicine, Division of Nephrology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Harold M Szerlip
- Department of Medicine, Division of Nephrology, Baylor University Medical Center at Dallas, Dallas, Texas
| |
Collapse
|
169
|
Barhight MF, Soranno D, Faubel S, Gist KM. Fluid Management With Peritoneal Dialysis After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:696-704. [PMID: 30322362 DOI: 10.1177/2150135118800699] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children who undergo cardiac surgery with cardiopulmonary bypass are a unique population at high risk for postoperative acute kidney injury (AKI) and fluid overload. Fluid management is important in the postoperative care of these children as fluid overload is associated with increased morbidity and mortality. Peritoneal dialysis catheters are an important tool in the armamentarium of a cardiac intensivist and are used for passive drainage for fluid removal or dialysis for electrolyte and uremia control in AKI. Prophylactic placement of a peritoneal catheter is a safe method of fluid removal that is associated with few major complications. Early initiation of peritoneal dialysis has been associated with improved clinical markers and outcomes such as early achievement of a negative fluid balance, lower vasoactive medication needs, shorter duration of mechanical ventilation, and decreased mortality. In this review, we discuss the safety and potential benefits of peritoneal catheters for dialysis or passive drainage in children following cardiopulmonary bypass.
Collapse
Affiliation(s)
- Matthew F Barhight
- 1 Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.,2 Department of Pediatrics, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Danielle Soranno
- 2 Department of Pediatrics, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,3 Division of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, USA.,4 Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Faubel
- 4 Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- 2 Department of Pediatrics, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,5 Division of Cardiology, Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
170
|
Huff C, Mastropietro CW, Riley C, Byrnes J, Kwiatkowski DM, Ellis M, Schuette J, Justice L. Comprehensive Management Considerations of Select Noncardiac Organ Systems in the Cardiac Intensive Care Unit. World J Pediatr Congenit Heart Surg 2018; 9:685-695. [PMID: 30322370 DOI: 10.1177/2150135118779072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As the acuity and complexity of pediatric patients with congenital cardiac disease have increased, there are many noncardiac issues that may be present in these patients. These noncardiac problems may affect clinical outcomes in the cardiac intensive care unit and must be recognized and managed. The Pediatric Cardiac Intensive Care Society sought to provide an expert review of some of the most common challenges of the respiratory, gastrointestinal, hematological, renal, and endocrine systems in pediatric cardiac patients. This review provides a brief overview of literature available and common practices.
Collapse
Affiliation(s)
- Christin Huff
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher W Mastropietro
- 2 Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | - Jonathan Byrnes
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Misty Ellis
- 5 Department of Pediatric Critical Care, University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | | | - Lindsey Justice
- 1 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
171
|
Cho MH, Kang HG. Acute kidney injury and continuous renal replacement therapy in children; what pediatricians need to know. KOREAN JOURNAL OF PEDIATRICS 2018; 61:339-347. [PMID: 30360040 PMCID: PMC6258966 DOI: 10.3345/kjp.2018.06996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/22/2018] [Indexed: 12/15/2022]
Abstract
Acute kidney injury (AKI) is characterized by abrupt deterioration of renal function, and its diagnosis relies on creatinine measurements and urine output. AKI is associated with higher morbidity and mortality, and is a risk factor for development of chronic kidney disease. There is no proven medication for AKI. Therefore, prevention and early detection are important. Physicians should be aware of the risk factors for AKI and should monitor renal function in high-risk patients. Management of AKI includes optimization of volume status and renal perfusion, avoidance of nephrotoxic agents, and sufficient nutritional support. Continuous renal replacement therapy is widely available for critically ill children, and this review provides basic information regarding this therapy. Long-term follow-up of patients with AKI for renal function, blood pressure, and proteinuria is recommended.
Collapse
Affiliation(s)
- Myung Hyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
172
|
Utilization of the renal angina index in PICU of a developing country for prediction of subsequent severe acute kidney injury. Pediatr Nephrol 2018; 33:2185-2191. [PMID: 29987453 DOI: 10.1007/s00467-018-4001-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/06/2018] [Accepted: 06/12/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is independently associated with worsened morbidity and increased mortality in the pediatric intensive care unit (PICU). AKI risk score, termed renal angina index (RAI) is used in developed countries to predict subsequent severe AKI. Very few studies have investigated application of RAI in the PICU of a developing country. This prospective observational study aimed to predict severe subsequent AKI in children admitted to PICU using RAI. METHODS Over 1 year, children admitted to PICU aged 1 month-18 years old, with no previous kidney disease, were included. RAI was assessed from 8 to 12 h of PICU admission (day 0). RAI was calculated from product of the renal risk and renal injury score. Renal angina positivity was defined as RAI ≥ 8. On day 3, serum creatinine was estimated and estimated glomerular filtrration rate (eGFR) calculated. RAI was correlated with presence/absence of subsequent (day 3) severe AKI. RAI positivity was also correlated with duration of PICU stay, need for dialysis, mechanical ventilation, and mortality. RESULTS RAI positivity was seen in 16.7% cases, of which 36.2% developed AKI at 4 days vs. 2.3% in RAI-negative cases (p < 0.001). Mean duration of PICU stay in the RAI-positive group was 7.19 ± 5.13 days vs. 4.72 ± 2.71 days in the RAI-negative group (p < 0.001). Mortality was seen in 31.9% of RAI-positive cases vs. 2% in RAI-negative cases (p < 0.001). CONCLUSIONS RAI could be used as a simple and important bedside tool to predict patients at risk of severe AKI.
Collapse
|
173
|
Barhight MF, Brinton J, Stidham T, Soranno DE, Faubel S, Griffin BR, Goebel J, Mourani PM, Gist KM. Increase in chloride from baseline is independently associated with mortality in critically ill children. Intensive Care Med 2018; 44:2183-2191. [PMID: 30382307 DOI: 10.1007/s00134-018-5424-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine if there is an association between mortality and admission chloride levels and/or increases in the chloride level in critically ill children. METHODS We performed a retrospective cohort study of all patients admitted to the paediatric intensive care unit (PICU) from January 2014 to December 2015. Patients were excluded for the following reasons: (1) age < 90 days or > 18 years, (2) admission to the cardiac intensive care unit, (3) no laboratory values upon admission to the PICU, (4) history of end-stage renal disease, (5) a disorder of chloride transport, and (6) admission for diabetic ketoacidosis. The patients were stratified on the basis of admission chloride levels (hypochloraemia, < 96 mEq/L; normochloraemia, 96-109 mEq/L; and hyperchloraemia, ≥ 110 mEq/L) and dichotomised on the basis of an increase in chloride in the first day (< 5 mEq/L, ≥ 5 mEq/L). Our primary outcome was in-hospital mortality. RESULTS A total of 1935 patients [55% female, median age 6.3 years IQR (1.9-13.4)] were included. The overall mortality was 4% (n = 71) and day 2 AKI occurred in 17% (n = 333. Hypochloraemia, hyperchloraemia, and an increase in serum chloride ≥ 5 mEq/L occurred in 2%, 21%, and 12%, respectively. After adjusting for confounders, increase in chloride ≥ 5 mEq/L was associated with a 2.3 (95% CI 1.03-5.21) greater odds of mortality. CONCLUSIONS An increase in serum chloride level in the first day of admission is common and an independent risk factor for mortality in critically ill children. Further studies are warranted to identify how chloride disturbances contribute to mortality risk in critically ill children.
Collapse
Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
| | - John Brinton
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy Stidham
- Division of Critical Care, Kalispell Regional Healthcare, Kalispell, MT, USA
| | - Danielle E Soranno
- Sections of Nephrology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Faubel
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin R Griffin
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Jens Goebel
- Sections of Nephrology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Sections of Critical Care, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Katja M Gist
- Sections of Cardiology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
174
|
|
175
|
Raina R, Sethi SK, Wadhwani N, Vemuganti M, Krishnappa V, Bansal SB. Fluid Overload in Critically Ill Children. Front Pediatr 2018; 6:306. [PMID: 30420946 PMCID: PMC6215821 DOI: 10.3389/fped.2018.00306] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/28/2018] [Indexed: 12/16/2022] Open
Abstract
Background: A common practice in the management of critically ill patients is fluid resuscitation. An excessive administration of fluids can lead to an imbalance in fluid homeostasis and cause fluid overload (FO). In pediatric critical care patients, FO can lead to a multitude of adverse effects and increased risk of morbidity. Objectives: To review the literature highlighting impact of FO on a multitude of outcomes in critically-ill children, causative vs. associative relationship of FO with critical illness and current pediatric fluid management guidelines. Data Sources: A literature search was conducted using PubMed/Medline and Embase databases from the earliest available date until June 2017. Data Extraction: Two authors independently reviewed the titles and abstracts of all articles which were assessed for inclusion. The manuscripts of studies deemed relevant to the objectives of this review were then retrieved and associated reference lists hand-searched. Data Synthesis: Articles were segregated into various categories namely pathophysiology and sequelae of fluid overload, assessment techniques, epidemiology and fluid management. Each author reviewed the selected articles in categories assigned to them. All authors participated in the final review process. Conclusions: Recent evidence has purported a relationship between mortality and FO, which can be validated by prospective RCTs (randomized controlled trials). The current literature demonstrates that "clinically significant" degree of FO could be below 10%. The lack of a standardized method to assess FB (fluid balance) and a universal definition of FO are issues that need to be addressed. To date, the impact of early goal directed therapy and utility of hemodynamic parameters in predicting fluid responsiveness remains underexplored in pediatric resuscitation.
Collapse
Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital and Cleveland Clinic Akron General, Akron, OH, United States
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, United States
| | - Sidharth Kumar Sethi
- Department of Nephrology, Kidney & Urology Institute, Medanta, The Medicity, Gurgaon, India
| | - Nikita Wadhwani
- Department of Nephrology, Kidney & Urology Institute, Medanta, The Medicity, Gurgaon, India
| | - Meghana Vemuganti
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Vinod Krishnappa
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, United States
- College of Graduate Studies, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Shyam B. Bansal
- Department of Nephrology, Kidney & Urology Institute, Medanta, The Medicity, Gurgaon, India
| |
Collapse
|
176
|
Riley AA, Watson M, Smith C, Guffey D, Minard CG, Currier H, Akcan Arikan A. Pediatric continuous renal replacement therapy: have practice changes changed outcomes? A large single-center ten-year retrospective evaluation. BMC Nephrol 2018; 19:268. [PMID: 30340544 PMCID: PMC6194595 DOI: 10.1186/s12882-018-1068-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 10/04/2018] [Indexed: 12/21/2022] Open
Abstract
Background To evaluate changes in population characteristics and outcomes in a large single-center pediatric patient cohort treated with continuous renal replacement therapy (CRRT) over a 10 year course, coincident with multiple institutional practice changes in CRRT delivery. Methods A retrospective cohort study with comparative analysis of all patients treated from 2004 to 2013 with CRRT in the neonatal, pediatric, and cardiovascular intensive care units within a free-standing pediatric tertiary care hospital. Results Three hundred eleven total patients were identified, 38 of whom received concurrent treatment with extracorporeal membrane oxygenation. 273 patients received CRRT only and were compared in two study eras (2004–2008 n = 129; 2009–2013 n = 144). Across eras, mean patient age decreased (9.2 vs 7.7 years, p = 0.08), and the most common principal diagnosis changed from cardiac to liver disease. There was an increase in patients treated with continuous renal replacement therapy between cohorts for acute kidney injury of multi factorial etiology (44% vs 56%) and a decrease in treated patients with sepsis (21% vs 11%, p = 0.04). There was no significant difference in survival to hospital discharge between eras (47% vs 49%). Improvement in outpatient follow-up after discharge amongst survivors was seen between study eras (33% vs 54%). Conclusions Despite multiple institutional practice changes in provision of CRRT, few changes were seen regarding patient demographics, diseases treated, indications for therapy, and survival over 10 years at a single tertiary care. Recognition of need for follow-up nephrology care following CRRT is improving. Ongoing assessment of the patient population in a changing landscape of care for critically ill pediatric patients remains important.
Collapse
Affiliation(s)
- Alyssa A Riley
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | | | | | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | | | - Ayse Akcan Arikan
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
177
|
Adherence to Daily Weights and Total Fluid Orders in the Pediatric Intensive Care Unit. Pediatr Qual Saf 2018; 3:e110. [PMID: 30584637 PMCID: PMC6221598 DOI: 10.1097/pq9.0000000000000110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/15/2018] [Indexed: 12/18/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background: Fluid is central to the resuscitation of critically ill children. However, many pay limited attention to continued fluid accumulation. Fluid overload (FO) is associated with significant morbidity and mortality. The Volume Status Awareness Program (VSAP) is a multi-phase quality improvement initiative aimed at reducing iatrogenic FO. For baseline data, the authors examined a retrospective cohort of patients admitted to the pediatric intensive care unit. Methods: Cohort included diuretic-naive patients admitted to the pediatric intensive care unit at a tertiary care children’s hospital in 2014. Furosemide-exposure was used to indicate provider-perceived FO. Variables included daily weight and total fluid (TF) orders, and their timing, frequency, and adherence. Implementation of VSAP phase 1 (bundle of interventions to promote consistent use of patient weights) occurred in June 2017. Results: Forty-nine patients met criteria. Five (10%) had daily weight orders, and 41 (84%) had TF orders—although 7 of these orders followed furosemide administration. Adherence to TF orders was good with 32 (78%) patients exceeding TF limits by < 10%. Thirty (63%) had > 5% FO by day 1, and 22 (51%) had > 10% cumulative FO by day 3. Following phase 1 of the VSAP, the frequency of daily weight orders increased from 6% to 88%. Conclusions: In our institution, use of fluid monitoring tools is both inconsistent and infrequent. Early data from the VSAP project suggests simple interventions can modify ordering and monitoring practice, but future improvement cycles are necessary to determine if these changes are successful in reducing iatrogenic FO
Collapse
|
178
|
Physician Awareness and Management Practices of Fluid Overload in Critically Ill Children. Pediatr Crit Care Med 2018; 19:1012-1014. [PMID: 30281576 DOI: 10.1097/pcc.0000000000001715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
179
|
Doi K, Nishida O, Shigematsu T, Sadahiro T, Itami N, Iseki K, Yuzawa Y, Okada H, Koya D, Kiyomoto H, Shibagaki Y, Matsuda K, Kato A, Hayashi T, Ogawa T, Tsukamoto T, Noiri E, Negi S, Kamei K, Kitayama H, Kashihara N, Moriyama T, Terada Y. The Japanese clinical practice guideline for acute kidney injury 2016. Clin Exp Nephrol 2018; 22:985-1045. [PMID: 30039479 PMCID: PMC6154171 DOI: 10.1007/s10157-018-1600-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention is necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.
Collapse
Affiliation(s)
- Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | | | - Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Noritomo Itami
- Department of Surgery, Kidney Center, Nikko Memorial Hospital, Hokkaido, Japan
| | - Kunitoshi Iseki
- Clinical Research Support Center, Tomishiro Central Hospital, Okinawa, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Hirokazu Okada
- Department of Nephrology and General Internal Medicine, Saitama Medical University, Saitama, Japan
| | - Daisuke Koya
- Division of Anticipatory Molecular Food Science and Technology, Department of Diabetology and Endocrinology, Kanazawa Medical University, Kanawaza, Ishikawa, Japan
| | - Hideyasu Kiyomoto
- Department of Community Medical Supports, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Kenichi Matsuda
- Department of Emergency and Critical Care Medicine, University of Yamanashi School of Medicine, Yamanashi, Japan
| | - Akihiko Kato
- Blood Purification Unit, Hamamatsu University Hospital, Hamamatsu, Japan
| | - Terumasa Hayashi
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Osaka, Japan
| | - Tomonari Ogawa
- Nephrology and Blood Purification, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tatsuo Tsukamoto
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eisei Noiri
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Shigeo Negi
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | | | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Toshiki Moriyama
- Health Care Division, Health and Counseling Center, Osaka University, Osaka, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
| |
Collapse
|
180
|
Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest 2018; 155:626-638. [PMID: 30266628 DOI: 10.1016/j.chest.2018.09.004] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 01/31/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is commonly used to provide renal support for critically ill patients with acute kidney injury, particularly patients who are hemodynamically unstable. A variety of techniques that differ in their mode of solute clearance may be used, including continuous venovenous hemofiltration with predominantly convective solute clearance, continuous venovenous hemodialysis with predominantly diffusive solute clearance, and continuous venovenous hemodiafiltration, which combines both dialysis and hemofiltration. The present article compares CRRT with other modalities of renal support and reviews indications for initiation of renal replacement therapy, as well as dosing and technical aspects in the management of CRRT.
Collapse
Affiliation(s)
- Srijan Tandukar
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul M Palevsky
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Renal Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, PA.
| |
Collapse
|
181
|
Doi K, Nishida O, Shigematsu T, Sadahiro T, Itami N, Iseki K, Yuzawa Y, Okada H, Koya D, Kiyomoto H, Shibagaki Y, Matsuda K, Kato A, Hayashi T, Ogawa T, Tsukamoto T, Noiri E, Negi S, Kamei K, Kitayama H, Kashihara N, Moriyama T, Terada Y. The Japanese Clinical Practice Guideline for acute kidney injury 2016. J Intensive Care 2018; 6:48. [PMID: 30123509 PMCID: PMC6088399 DOI: 10.1186/s40560-018-0308-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 06/22/2018] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention are necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.
Collapse
Affiliation(s)
- Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Aichi Japan
| | | | - Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba, Japan
| | - Noritomo Itami
- Kidney Center, Department of Surgery, Nikko Memorial Hospital, Hokkaido, Japan
| | - Kunitoshi Iseki
- Clinical Research Support Center, Tomishiro Central Hospital, Okinawa, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi Japan
| | - Hirokazu Okada
- Department of Nephrology and General Internal Medicine, Saitama Medical University, Saitama, Japan
| | - Daisuke Koya
- Division of Anticipatory Molecular Food Science and Technology, Department of Diabetology and Endocrinology, Kanazawa Medical University, Kanawaza, Ishikawa Japan
| | - Hideyasu Kiyomoto
- Department of Community Medical Supports, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Kawasaki, Kanagawa Japan
| | - Kenichi Matsuda
- Department of Emergency and Critical Care Medicine, University of Yamanashi School of Medicine, Yamanashi, Japan
| | - Akihiko Kato
- Blood Purification Unit, Hamamatsu University Hospital, Hamamatsu, Japan
| | - Terumasa Hayashi
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Osaka, Japan
| | - Tomonari Ogawa
- Nephrology and Blood Purification, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tatsuo Tsukamoto
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eisei Noiri
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Shigeo Negi
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | | | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Toshiki Moriyama
- Health Care Division, Health and Counseling Center, Osaka University, Osaka, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505 Japan
| |
Collapse
|
182
|
Leow EH, Chan YH, Ng YH, Lim JKB, Nakao M, Lee JH. Prevention of Acute Kidney Injury in Children Undergoing Cardiac Surgery: A Narrative Review. World J Pediatr Congenit Heart Surg 2018; 9:79-90. [PMID: 29310552 DOI: 10.1177/2150135117743211] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery are at risk of developing acute kidney injury (AKI). Preventing cardiac surgery-associated AKI (CS-AKI) is important as it is associated with increased early- and long-term mortality and morbidity. Targeting modifiable risk factors (eg, avoiding poor renal perfusion, nephrotoxic drugs, and fluid overload) reduces the risk of CS-AKI. There is currently no strong evidence for the routine use of pharmacological approaches (eg, aminophylline, dexmedetomidine, fenoldopam, and steroids) to prevent CS-AKI. There is robust evidence to support the role of early peritoneal dialysis as a nonpharmacologic approach to prevent CS-AKI.
Collapse
Affiliation(s)
- Esther Huimin Leow
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
| | - Yong Hong Ng
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Joel Kian Boon Lim
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Masakazu Nakao
- 4 Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
| |
Collapse
|
183
|
Sinha R, Sethi SK, Bunchman T, Lobo V, Raina R. Prolonged intermittent renal replacement therapy in children. Pediatr Nephrol 2018; 33:1283-1296. [PMID: 28721515 DOI: 10.1007/s00467-017-3732-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/22/2017] [Accepted: 05/31/2017] [Indexed: 12/15/2022]
Abstract
Wide ranges of age and weight in pediatric patients makes renal replacement therapy (RRT) in acute kidney injury (AKI) challenging, particularly in the pediatric intensive care unit (PICU), wherein children are often hemodynamically unstable. Standard hemodialysis (HD) is difficult in this group of children and continuous veno-venous hemofiltration/dialysis (CVVH/D) has been the accepted modality in the developed world. Unfortunately, due to cost constraints, CVVH/D is often not available and peritoneal dialysis (PD) remains the common mode of RRT in resource-poor facilities. Acute PD has its drawbacks, and intermittent HD (IHD) done slowly over a prolonged period has been explored as an alternative. Various modes of slow sustained IHD have been described in the literature with the recently introduced term prolonged intermittent RRT (PIRRT) serving as an umbrella terminology for all of these modes. PIRRT has been widely accepted in adults with studies showing it to be as effective as CVVH/D but with an added advantage of being more cost-effective. Pediatric data, though scanty, has been promising. In this current review, we elaborate on the practical aspects of undertaking PIRRT in children as well as summarize its current status.
Collapse
Affiliation(s)
- Rajiv Sinha
- Institute of Child Health and AMRI Hospital, 37, G Bondel Road, Kolkata, West Bengal, 700019, India.
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Timothy Bunchman
- Pediatric Nephrology, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Valentine Lobo
- Department of Nephrology, KEM Hospital, Pune, Maharashtra, India
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA
| |
Collapse
|
184
|
Bernardo EO, Cruz AT, Buffone GJ, Devaraj S, Loftis LL, Arikan AA. Community-acquired Acute Kidney Injury Among Children Seen in the Pediatric Emergency Department. Acad Emerg Med 2018; 25:758-768. [PMID: 29630763 DOI: 10.1111/acem.13421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/13/2018] [Accepted: 03/24/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a significant risk factor for morbidity and mortality in children. Little is known about community-acquired AKI (CA-AKI) in the pediatric emergency department (PED). Early recognition of AKI allows for nephroprotective measures. The goal of this investigation was to determine the incidence of CA-AKI and the frequency of clinician identified CA-AKI to better inform future nephroprotective interventions. METHODS This was a retrospective cross-sectional study in the PED of a children's hospital. Children 1 month to 18 years of age seen in the PED from January 1 to December 31, 2015, and in whom at least one creatinine level was obtained were included. Patients with chronic kidney disease or end-stage renal disease or who died in the PED were excluded. Patients had CA-AKI based on modified Kidney Disease-Improving Global Outcomes criteria using the creatinine obtained in the PED compared to age-specific norms. Patients were considered identified if the PED clinician diagnosed AKI. The primary outcome was the incidence of CA-AKI. Secondary outcomes included frequency of AKI identification, nephrotoxic medication use, hospital length of stay, renal replacement therapy, and death. Fisher exact test or Pearson's chi-square test was used to calculate odds ratio (OR) with 95% confidence intervals (CIs); multivariable analyses were performed using logistic regression. RESULTS In 2015 there were 119,151 PED visits; 15,486 met inclusion criteria. CA-AKI was present in 239 of 15,486 (1.5%) encounters. AKI was identified by PED clinicians in 46 of 239 (19%) of encounters and by the inpatient team in 123 of 199 (62%) of the encounters admitted. AKI was never recognized by a PED or inpatient clinician in 74 of 199 (37%) encounters. Encounters with AKI correctly diagnosed were older (13 years old vs. 10 years old, p = 0.0114), had more severe (stage 2 or 3) AKI (OR = 5.5, 95% CI = 2.6-11.8), and were more likely to be admitted (OR = 10.3, 95% CI = 1.38-77.4) than encounters with missed AKI. CONCLUSIONS CA-AKI remains an underrecognized entity in the PED. Better tools for early recognition of AKI in the busy PED environment are needed.
Collapse
Affiliation(s)
- Erika O. Bernardo
- Department of Pediatrics Section of Critical Care Medicine Baylor College of Medicine Houston TX
| | - Andrea T. Cruz
- Department of Pediatrics Sections of Emergency Medicine and Infectious Diseases Baylor College of Medicine Houston TX
| | | | - Sridevi Devaraj
- Department of Pathology Baylor College of Medicine Houston TX
| | - Laura L. Loftis
- Department of Pediatrics Section of Critical Care Medicine Baylor College of Medicine Houston TX
| | - Ayse Akcan Arikan
- Department of Pediatrics Section of Critical Care Medicine Baylor College of Medicine Houston TX
| |
Collapse
|
185
|
Al-Ayed T, Rahman NU, Alturki A, Aljofan F. Outcome of continuous renal replacement therapy in critically ill children: a retrospective cohort study. Ann Saudi Med 2018; 38:260-268. [PMID: 30078024 PMCID: PMC6086670 DOI: 10.5144/0256-4947.2018.260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) has become the preferred mode of dialysis to support critically ill children with acute kidney injury. However, there are limited pediatric data on CRRT use, especially in our region. OBJECTIVE Determine the outcome of CRRT among critically ill children. DESIGN Retrospective cohort study. SETTING Pediatric intensive care unit. PATIENTS AND METHODS The study included critically ill children 1-14 years of age who underwent CRRT from July 2009 to June 2015. We report the underlying diagnosis, demographics, indications and modality of CRRT, and associated risk factors. Statistical analyses were used to identify risk factors associated with mortality. MAIN OUTCOME MEASURES Mortality and associated risk factors with use of CRRT. SAMPLE SIZE 96 RESULTS: The mean age was 6.0 (standard deviation, 4.4) years, with a male preponderance in the age group from 1-10 years which comprised almost 60% of the study group. The most common primary diagnoses were malignancies [37.5% (36/96)] followed by primary renal diseases [19.8% (19/96)], and immunodeficiency [16.7% (16/96)]. The most common indication for CRRT was fluid overload [67.2% (65/96)] followed by tumor lysis syndrome [18.8%(18/96)], and metabolic encephalopathy [9.4%(9/96)]. The median length of CRRT was 66 hours (IQR, 35.5-161.4), with a median average circuit life of 30.9 hours (IQR, 16.4-45.0). The most common CRRT catheter site was the internal jugular vein [77.1% (74/96)], followed by the femoral vein [18.8%(18/96)] with continuous venovenous hemodiafiltration [82.3%(79/96)] being the most common CRRT modality used. The mortality rate among critically ill children requiring CRRT was 50% (48/96). There was an increased mortality rate among children with hematological diseases (100%, 10/10), immunodeficiency (86.6%, 13/16) and in children who had undergone stem cell transplantation (90.0%, 27/30), with the least mortality in primary renal disease (15.8% (3/19). We identified septic shock and use of inotropic support as being independently associated with mortality in a multivariate analysis. CONCLUSION The overall mortality rate among critically ill children who un.derwent CRRT was 50% with significantly increased mortality among patients with hematological diseases, immunodeficiency, and in children who had undergone stem cell transplantation. Septic shock and use of inotropic support were associated with mortality. LIMITATIONS Retrospective and single center data that is not generalizable. CONFLICT OF INTEREST None.
Collapse
Affiliation(s)
- Tareq Al-Ayed
- Dr. Tareq Al-Ayed, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, Riyadh 11211, Saudi Arabia, T: +96614427763 F: +96614427784, , ORCID: http://orcid.org/0000-0001-7525-3529
| | | | | | | |
Collapse
|
186
|
Díaz F, Nuñez MJ, Pino P, Erranz B, Cruces P. Implementation of preemptive fluid strategy as a bundle to prevent fluid overload in children with acute respiratory distress syndrome and sepsis. BMC Pediatr 2018; 18:207. [PMID: 29945586 PMCID: PMC6020419 DOI: 10.1186/s12887-018-1188-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 06/21/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Fluid overload (FO) is associated with unfavorable outcomes in critically ill children. Clinicians are encouraged to avoid FO; however, strategies to avoid FO are not well-described in pediatrics. Our aim was to implement a bundle strategy to prevent FO in children with sepsis and pARDS and to compare the outcomes with a historical cohort. METHODS A quality improvement initiative, known as preemptive fluid strategy (PFS) was implemented to prevent early FO, in a 12-bed general PICU. Infants on mechanical ventilation (MV) fulfilling pARDS and sepsis criteria were prospectively recruited. For comparison, data from a historical cohort from 2015, with the same inclusion and exclusion criteria, was retrospectively reviewed. The PFS bundle consisted of 1. maintenance of intravenous fluids (MIVF) at 50% of requirements; 2. drug volume reduction; 3. dynamic monitoring of preload markers to determine the need for fluid bolus administration; 4. early use of diuretics; and 5. early initiation of enteral feeds. The historical cohort treatment, the standard fluid strategy (SFS), were based on physician preferences. Peak fluid overload (PFO) was the primary outcome. PFO was defined as the highest FO during the first 72 h. FO was calculated as (cumulative fluid input - cumulative output)/kg*100. Fluid input/output were registered every 12 h for 72 h. RESULTS Thirty-seven patients were included in the PFS group (54% male, 6 mo (IQR 2,11)) and 39 with SFS (64%male, 3 mo (IQR1,7)). PFO was lower in PFS (6.31% [IQR4.4-10]) compared to SFS (12% [IQR8.4-15.8]). FO was lower in PFS compared to CFS as early as 12 h after admission [2.4(1.4,3.7) v/s 4.3(1.5,5.5), p < 0.01] and maintained during the study. These differences were due to less fluid input (MIVF and fluid boluses). There were no differences in the renal function test. PRBC requirements were lower during the first 24 h in the PFS (5%) compared to SFS (28%, p < 0.05). MV duration was 81 h (58,98) in PFS and 118 h (85154) in SFS(p < 0.05). PICU LOS in PFS was 5 (4, 7) and in SFS was 8 (6, 10) days. CONCLUSION Implementation of a bundle to prevent FO in children on MV with pARDS and sepsis resulted in less PFO. We observed a decrease in MV duration and PICU LOS. Future studies are needed to address if PFS might have a positive impact on health outcomes.
Collapse
Affiliation(s)
- Franco Díaz
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile.,Pediatric Intensive Care Unit, Clínica Alemana de Santiago, Santiago, Chile.,Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - María José Nuñez
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile
| | - Pablo Pino
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile
| | - Benjamín Erranz
- Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Pablo Cruces
- Pediatric Intensive Care Unit, Hospital El Carmen de Maipú, Santiago, Chile. .,Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Avda. Republica 217, Santiago, Chile.
| |
Collapse
|
187
|
Ponce D, Góes C, Oliveira M, Balbi A. Peritoneal Dialysis for the Treatment of Cardiorenal Syndrome Type 1: A Prospective Brazilian Study. Perit Dial Int 2018; 37:578-583. [PMID: 28931700 DOI: 10.3747/pdi.2016.00217] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
This study aimed to explore the role of high-volume peritoneal dialysis (HVPD) in cardiorenal syndrome (CRS) type 1 patients in relation to metabolic and fluid control and outcome. Sixty-four patients were treated by HVPD (prescribed Kt/V = 0.50/session), flexible catheter and cycler. Mean age was 68.8 ± 15.4 years, 54.7% needed intravenous inotropic agents and/or intravenous vasodilators, 31.2% were on mechanical ventilation, acute coronary syndrome (ACS) was the main cause of acute disease heart failure (ADHF) 48.3%, median left ventricular ejection fraction (LVEF) was 38% and the main dialysis indications were uremia and hypervolemia. Blood ureic nitrogen and creatinine levels stabilized after 4 sessions at around 50 and 4 mg/dL, respectively. Negative fluid balance (FB) and ultrafiltration (UF) increased progressively and stabilized around 2.6 L and -2.5 L/day, respectively. Weekly-delivered Kt/V was 3.0 ± 0.42, and 32.8% died. There was a significant difference between the survivors (S) and non-survivors (NS) in age (71.4 ± 15.7 vs 63.6 ± 17.6, p < 0.001), main diagnosis of ADHF (ACS: 76.2 vs 34.8%, p = 0.04), mechanical ventilation (52.4 vs 20.1%, p = 0.03), fluid overload (FO) at predialysis moment (52.4 vs 25.6%, p = 0.04), and FB and UF from the 2nd to 5th dialysis session. In conclusion, HVPD treatment was effective in CRS type 1 patients, allowing adequate metabolic and fluid control. Age, ACS, FO and positive FB after 2 HVPD sessions were higher in NS patients.
Collapse
Affiliation(s)
- Daniela Ponce
- Botucatu School of Medicine - UNESP, Internal Medicine, Botucatu, Brazil
| | - Cassiana Góes
- Botucatu School of Medicine - UNESP, Internal Medicine, Botucatu, Brazil
| | - Mariele Oliveira
- Botucatu School of Medicine - UNESP, Internal Medicine, Botucatu, Brazil
| | - Andre Balbi
- Botucatu School of Medicine - UNESP, Internal Medicine, Botucatu, Brazil
| |
Collapse
|
188
|
Barhight MF, Lusk J, Brinton J, Stidham T, Soranno DE, Faubel S, Goebel J, Mourani PM, Gist KM. Hyperchloremia is independently associated with mortality in critically ill children who ultimately require continuous renal replacement therapy. Pediatr Nephrol 2018; 33:1079-1085. [PMID: 29404689 DOI: 10.1007/s00467-018-3898-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/20/2017] [Accepted: 01/19/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal fluid management in critically ill children is currently under investigation with several studies suggesting that hyperchloremia, chloride load, and the use of chloride-rich fluids contribute to worse outcomes. METHODS This is a single-center retrospective cohort study of Pediatric Intensive Care Unit patients from 2008 to 2016 requiring continuous renal replacement therapy (CRRT). Patients were excluded if they had end-stage renal disease, a disorder of chloride transport, or concurrent provision of extracorporeal membrane oxygenation therapy. RESULTS Patients (n = 66) were dichotomized into two groups (peak chloride (Cl) ≥ 110 mmol/L vs. peak Cl < 110 mmol/L prior to CRRT initiation). Hyperchloremia was present in 39 (59%) children. Baseline characteristics were similar between groups. Fluid overload at CRRT initiation was more common in patients with hyperchloremia (11.5% IQR 3.8-22.4) compared to those without (5.5% IQR 0.9-13.9) (p = 0.04). Mortality was significantly higher in patients with hyperchloremia (n = 26, 67%) compared to those without (n = 8, 29%) (p = 0.006). Patients with hyperchloremia had 10.9 times greater odds of death compared to those without hyperchloremia, after adjusting for percent fluid overload, PRISM III score, time to initiation of CRRT, height, and weight (95% CI 2.4 to 49.5, p = 0.002). CONCLUSIONS Hyperchloremia is common among critically ill children prior to CRRT initiation. In this population, hyperchloremia is independently associated with mortality. Further studies are needed to determine the impact of hyperchloremia on all critically ill children and the impact of chloride load on outcomes.
Collapse
Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer Lusk
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA
| | - John Brinton
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy Stidham
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Danielle E Soranno
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Division of Nephrology, Children's Hospital Colorado, Aurora, CO, USA.,Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Faubel
- Division of Nephrology, Children's Hospital Colorado, Aurora, CO, USA.,Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jens Goebel
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Division of Nephrology, Children's Hospital Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,Division of Cardiology, Children's Hospital Colorado, Aurora, CO, USA. .,The Heart Institute, Children's Hospital Colorado, 13123 E. 16th Ave, Box 100, Aurora, CO, 80045-2535, USA.
| |
Collapse
|
189
|
|
190
|
Abstract
PURPOSE OF REVIEW The past decade has seen more advances in our understanding of fluid therapy than the preceding decades combined. What was once thought to be a relatively benign panacea is increasingly being recognized as a potent pharmacological and physiological intervention that may pose as much harm as benefit. RECENT FINDINGS Recent studies have clearly indicated that the amount, type, and timing of fluid administration have profound effects on patient morbidity and outcomes. The practice of aggressive volume resuscitation for 'renal protection' and 'hemodynamic support' may in fact be contributing to end organ dysfunction. The practice of early goal-directed therapy for patients suffering from critical illness or undergoing surgery appears to offer no benefit over conventional therapy and may in fact be harmful. A new conceptual model for fluid resuscitation of critically ill patients has recently been developed and is explored here. SUMMARY The practice of giving more fluid early and often is being replaced with new conceptual models of fluid resuscitation that suggest fluid therapy be 'personalized' to individual patient pathophysiology.
Collapse
|
191
|
Sethi SK, Bansal SB, Khare A, Dhaliwal M, Raghunathan V, Wadhwani N, Nandwani A, Yadav DK, Mahapatra AK, Raina R. Heparin free dialysis in critically sick children using sustained low efficiency dialysis (SLEDD-f): A new hybrid therapy for dialysis in developing world. PLoS One 2018; 13:e0195536. [PMID: 29698409 PMCID: PMC5919674 DOI: 10.1371/journal.pone.0195536] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 03/23/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In critically sick adults, sustained low efficiency dialysis [SLED] appears to be better tolerated hemodynamically and outcomes seem to be comparable to CRRT. However, there is paucity of data in critically sick children. In children, two recent studies from Taiwan (n = 11) and India (n = 68) showed benefits of SLED in critically sick children. AIMS AND OBJECTIVES The objective of the study was to look at the feasibility and tolerability of sustained low efficiency daily dialysis-filtration [SLEDD-f] in critically sick pediatric patients. MATERIAL AND METHODS Design: Retrospective study Inclusion criteria: All pediatric patients who had undergone heparin free SLEDD-f from January 2012 to October 2017. Measurements: Data collected included demographic details, vital signs, PRISM III at admission, ventilator parameters (where applicable), number of inotropes, blood gas and electrolytes before, during, and on conclusion of SLED therapy. Technical information was gathered regarding SLEDD-f prescription and complications. RESULTS Between 2012-2017, a total of 242 sessions of SLEDD-f were performed on 70 patients, out of which 40 children survived. The median age of patients in years was 12 (range 0.8-17 years), and the median weight was 39 kg (range 8.5-66 kg). The mean PRISM score at admission was 8.77±7.22. SLEDD-f sessions were well tolerated, with marked improvement in fluid status and acidosis. Premature terminations had to be done in 23 (9.5%) of the sessions. There were 21 sessions (8.6%) terminated due to hypotension and 2 sessions (0.8%) terminated due to circuit clotting. Post- SLEDD-f hypocalcemia occurred in 15 sessions (6.2%), post- SLEDD-f hypophosphatemia occurred in 1 session (0.4%), and post- SLEDD-f hypokalemia occurred in 17 sessions (7.0%). CONCLUSIONS This study is the largest compiled data on pediatric SLEDD-f use in critically ill patients. Our study confirms the feasibility of heparin free SLEDD-f in a larger pediatric population, and even in children weighing <20 kg on inotropic support.
Collapse
Affiliation(s)
| | - Shyam B. Bansal
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Anshika Khare
- Northeast Ohio Medical University, Rootstown, Ohio, United States of America
| | - Maninder Dhaliwal
- Pediatric Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Veena Raghunathan
- Pediatric Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Nikita Wadhwani
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Ashish Nandwani
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | | | | | - Rupesh Raina
- Pediatric Nephrology, Akron Children’s Hospital, Akron, Ohio, United States of America
- * E-mail:
| |
Collapse
|
192
|
Pan T, Li D, Li S, Yan J, Wang X. Early initiation of peritoneal dialysis improves postoperative recovery in children with right ventricular outflow tract obstructive lesions at high risk of fluid overload: a propensity score-matched analysis. Interact Cardiovasc Thorac Surg 2018. [PMID: 29534186 DOI: 10.1093/icvts/ivy048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tuo Pan
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Dan Li
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Department of Pediatric Cardiac Surgery, National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jun Yan
- Department of Pediatric Cardiac Surgery, National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| |
Collapse
|
193
|
Long E, Duke T, Oakley E, O'Brien A, Sheridan B, Babl FE. Does respiratory variation of inferior vena cava diameter predict fluid responsiveness in spontaneously ventilating children with sepsis. Emerg Med Australas 2018. [PMID: 29520998 DOI: 10.1111/1742-6723.12948] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The intent of fluid bolus therapy (FBT) is to increase cardiac output and tissue perfusion, yet only 50% of septic children are fluid responsive. We evaluated respiratory variation of inferior vena cava (IVC) diameter as a predictor of fluid responsiveness. METHODS A prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Patients were spontaneously ventilating children treated with FBT for sepsis-induced acute circulatory failure. IVC ultrasound was performed prior to FBT. Trans-thoracic echocardiography was performed prior to, 5 and 60 min after FBT. IVC collapsibility index and stroke distance were calculated by a blinded Paediatric Emergency Physician and blinded Paediatric Cardiologist, respectively. RESULTS Thirty-nine fluid boluses were recorded in 33 children, 28/39 (72%) of which met criteria for fluid responsiveness at 5 min, which was sustained in 2/28 (7%) of initial fluid responders at 60 min. Sensitivity and specificity (95% confidence interval) of IVC collapsibility index were 0.44 (0.25-0.65) and 0.33 (0.10-0.65) with an area under the receiver operator characteristics curve (95% confidence interval) of 0.38 (0.23-0.55) at 5 min. Test characteristics 60 min after fluid bolus administration were not meaningful because of the infrequency of sustained fluid responsiveness in this patient group. There was no significant correlation between IVC collapsibility and fluid responsiveness at 5 or 60 min. CONCLUSIONS IVC collapsibility has poor test characteristics for predicting fluid responsiveness in spontaneously ventilating children with sepsis.
Collapse
Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Duke
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ed Oakley
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam O'Brien
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bennett Sheridan
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | | |
Collapse
|
194
|
Nagpal A, Clingenpeel MM, Thakkar RK, Fabia R, Lutmer J. Positive cumulative fluid balance at 72h is associated with adverse outcomes following acute pediatric thermal injury. Burns 2018; 44:1308-1316. [PMID: 29929899 DOI: 10.1016/j.burns.2018.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/06/2018] [Accepted: 01/27/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine the association between fluid resuscitation volume following pediatric burn injury and impact on outcomes. METHODS A retrospective chart review of pediatric patients (0-18 years) sustaining ≥15% TBSA burn, admitted to an American Burn Association verified pediatric burn center from 2010 to 2015. RESULTS Twenty-seven patients met inclusion criteria and had complete data available for analysis. Fifteen (56%) patients received greater than 6ml/kg/total body surface area burn in first 24h and twelve (44%) patients received less than 6ml/kg/percent total body surface area burn in first 24h. There were no differences between groups in median number of mechanical ventilator days (4 vs 8, p=0.96), intensive care unit length of stay (10 vs 13.5, p=0.75), or hospital length of stay (37 vs 37.5, p=0.56). Secondary analysis revealed that patients with a higher mean cumulative fluid overload (>253ml/kg, n=16) had larger burn size, higher injury severity scores, and were more likely to receive mechanical ventilation and invasive support devices. Controlling for burn size, odds of longer PICU length of stay and duration of mechanical ventilation were 20.33 [95% CI (1.7-235.6) p=0.02] and 27.9 [95% CI (2.1-364.7) p=0.01], respectively, among patients with a high cumulative fluid overload on day 3 compared to low cumulative fluid overload. CONCLUSIONS Resuscitation volume in the first 24h was not associated with adverse outcomes. Persistent cumulative fluid overload at day 3 and beyond was independently associated with adverse outcomes.
Collapse
Affiliation(s)
- Ashish Nagpal
- Department of Pediatrics, Division of Critical Care Medicine, The Children's Hospital at OU Medical Center, 1200 Children's Ave, Oklahoma City, OK, 73104, United States.
| | - Melissa-Moore Clingenpeel
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43215, United States; Biostatistics Core, The Research Institute, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, United States.
| | - Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, United States; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210, United States.
| | - Renata Fabia
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, United States; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210, United States.
| | - Jeffrey Lutmer
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43215, United States; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210, United States.
| |
Collapse
|
195
|
Abstract
OBJECTIVES Although renal replacement therapy is widely used in critically ill children, there have been few comprehensive population-based studies of its use. This article describes renal replacement therapy use, and associated outcomes, in critically ill children across the United Kingdom in the largest cohort study of this patient group. DESIGN A retrospective observational study using prospectively collected data. SETTING Data from the Pediatric Intensive Care Audit Network database which collects data on all children admitted to U.K. PICUs. PATIENTS Children (< 16 yr) in PICU who received renal replacement therapy between January 1, 2005, and December 31, 2012, were identified. INTERVENTIONS Individual-level data including age, underlying diagnosis, modality (peritoneal dialysis and continuous extracorporeal techniques [continuous renal replacement therapy]), duration of renal replacement therapy, PICU length of stay, and survival were extracted. MEASUREMENTS AND MAIN RESULTS Three-thousand eight-hundred twenty-five of 129,809 PICU admissions (2.9%) received renal replacement therapy in 30 of 33 centers. Volumes of renal replacement therapy varied considerably from 0% to 8.6% of PICU admissions per unit, but volume was not associated with patient survival. Overall survival to PICU discharge (73.8%) was higher than previous reports. Mortality risk was related to age, with lower risk in older children compared with neonates (odds ratio, 0.6; 95% CI, 0.5-0.8) although mortality did not increase over the age of 1 year; mode of renal replacement therapy, with lower risk in peritoneal dialysis than continuous renal replacement therapy methodologies (odds ratio, 0.7; 0.5-0.9); duration of renal replacement therapy (odds ratio, 1.02/d; 95% CI, 1.01-1.04); and primary diagnosis, with the lowest survival in liver disease patients (53.9%). CONCLUSIONS This study describes current renal replacement therapy use across the United Kingdom and associated outcomes. We describe a number of factors associated with outcome, including age, underlying diagnosis, and renal replacement therapy modality which will need to be factored into future trial design.
Collapse
|
196
|
Fluid overload independent of acute kidney injury predicts poor outcomes in neonates following congenital heart surgery. Pediatr Nephrol 2018; 33:511-520. [PMID: 29128923 DOI: 10.1007/s00467-017-3818-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/09/2017] [Accepted: 09/28/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Fluid overload (FO) is common after neonatal congenital heart surgery and may contribute to mortality and morbidity. It is unclear if the effects of FO are independent of acute kidney injury (AKI). METHODS This was a retrospective cohort study which examined neonates (age < 30 days) who underwent cardiopulmonary bypass in a university-affiliated children's hospital between 20 October 2010 and 31 December 2012. Demographic information, risk adjustment for congenital heart surgery score, surgery type, cardiopulmonary bypass time, cross-clamp time, and vasoactive inotrope score were recorded. FO [(fluid in-out)/pre-operative weight] and AKI defined by Kidney Disease Improving Global Outcomes serum creatinine criteria were calculated. Outcomes were all-cause, in-hospital mortality and median postoperative hospital and intensive care unit lengths of stay. RESULTS Overall, 167 neonates underwent cardiac surgery using cardiopulmonary bypass in the study period, of whom 117 met the inclusion criteria. Of the 117 neonates included in the study, 76 (65%) patients developed significant FO (>10%), and 25 (21%) developed AKI ≥ Stage 2. When analyzed as FO cohorts (< 10%,10-20%, > 20% FO), patients with greater FO were more likely to have AKI (9.8 vs. 18.2 vs. 52.4%, respectively, with AKI ≥ stage 2; p = 0.013) and a higher vasoactive-inotrope score, and be premature. In the multivariable regression analyses of patients without AKI, FO was independently associated with hospital and intensive care unit lengths of stay [0.322 extra days (p = 0.029) and 0.468 extra days (p < 0.001), respectively, per 1% FO increase). In all patients, FO was also associated with mortality [odds ratio 1.058 (5.8% greater odds of mortality per 1% FO increase); 95% confidence interval 1.008,1.125;p = 0.032]. CONCLUSIONS Fluid overload is an important independent contributor to outcomes in neonates following congenital heart surgery. Careful fluid management after cardiac surgery in neonates with and without AKI is warranted.
Collapse
|
197
|
Alobaidi R, Morgan C, Basu RK, Stenson E, Featherstone R, Majumdar SR, Bagshaw SM. Association Between Fluid Balance and Outcomes in Critically Ill Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2018; 172:257-268. [PMID: 29356810 PMCID: PMC5885847 DOI: 10.1001/jamapediatrics.2017.4540] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE After initial resuscitation, critically ill children may accumulate fluid and develop fluid overload. Accruing evidence suggests that fluid overload contributes to greater complexity of care and worse outcomes. OBJECTIVE To describe the methods to measure fluid balance, define fluid overload, and evaluate the association between fluid balance and outcomes in critically ill children. DATA SOURCES Systematic search of MEDLINE, EMBASE, Cochrane Library, trial registries, and selected gray literature from inception to March 2017. STUDY SELECTION Studies of children admitted to pediatric intensive care units that described fluid balance or fluid overload and reported outcomes of interest were included. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS All stages were conducted independently by 2 reviewers. Data extracted included study characteristics, population, fluid metrics, and outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale. Narrative description of fluid assessment methods and fluid overload definitions was done. When feasible, pooled analyses were performed using random-effects models. MAIN OUTCOMES AND MEASURES Mortality was the primary outcome. Secondary outcomes included treatment intensity, organ failure, and resource use. RESULTS A total of 44 studies (7507 children) were included in this systematic review and meta-analysis. Of those, 27 (61%) were retrospective cohort studies, 13 (30%) were prospective cohort studies, 3 (7%) were case-control studies, and 1 study (2%) was a secondary analysis of a randomized trial. The proportion of children with fluid overload varied by case mix and fluid overload definition (median, 33%; range, 10%-83%). Fluid overload, however defined, was associated with increased in-hospital mortality (17 studies [n = 2853]; odds ratio [OR], 4.34 [95% CI, 3.01-6.26]; I2 = 61%). Survivors had lower percentage fluid overload than nonsurvivors (22 studies [n = 2848]; mean difference, -5.62 [95% CI, -7.28 to -3.97]; I2 = 76%). After adjustment for illness severity, there was a 6% increase in odds of mortality for every 1% increase in percentage fluid overload (11 studies [n = 3200]; adjusted OR, 1.06 [95% CI, 1.03-1.10]; I2 = 66%). Fluid overload was associated with increased risk for prolonged mechanical ventilation (>48 hours) (3 studies [n = 631]; OR, 2.14 [95% CI, 1.25-3.66]; I2 = 0%) and acute kidney injury (7 studies [n = 1833]; OR, 2.36 [95% CI, 1.27-4.38]; I2 = 78%). CONCLUSIONS AND RELEVANCE Fluid overload is common and is associated with substantial morbidity and mortality in critically ill children. Additional research should now ideally focus on interventions aimed to mitigate the potential for harm associated with fluid overload.
Collapse
Affiliation(s)
- Rashid Alobaidi
- Division of Pediatric Critical Care, Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada
| | - Catherine Morgan
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rajit K. Basu
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Erin Stenson
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robin Featherstone
- Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, Alberta Research Center for Health Evidence (ARCHE), Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sumit R. Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| |
Collapse
|
198
|
Fuhrman DY, Kane-Gill S, Goldstein SL, Priyanka P, Kellum JA. Acute kidney injury epidemiology, risk factors, and outcomes in critically ill patients 16-25 years of age treated in an adult intensive care unit. Ann Intensive Care 2018; 8:26. [PMID: 29445884 PMCID: PMC5812957 DOI: 10.1186/s13613-018-0373-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 02/09/2018] [Indexed: 01/17/2023] Open
Abstract
Background Most studies of acute kidney injury (AKI) have focused on older adults, and little is known about AKI in young adults (16–25 years) that are cared for in an adult intensive care unit (ICU). We analyzed data from a large single-center ICU database and defined AKI using the Kidney Disease Improving Global Outcomes criteria. We stratified patients 16–55 years of age into four age groups for comparison and used multivariable logistic regression to identify associations of potential susceptibilities and exposures with AKI and mortality. Results AKI developed in 52.6% (n = 8270) of the entire cohort and in 39.8% of the young adult age group (16–25 years). The AUCs for the age categories were similar at 0.754, 0.769, 0.772, and 0.770 for the 16–25-, 26–35-, 36–45-, and 45–55-year age groups, respectively. For the youngest age group, diabetes (OR 1.89; 95% CI 1.09–3.29), surgical reason for admission (OR 1.79; 95% CI 1.44–2.23), severity of illness (OR 1.02; 95% CI 1.02–1.03), hypotension (OR 1.13; 95% CI 1.04–1.24), and certain medications (vancomycin and calcineurin inhibitors) were all independently associated with AKI. AKI was a significant predictor for longer length of stay, ICU mortality, and mortality after discharge. Conclusions AKI is a common event for young adults admitted to an adult tertiary care center ICU with an associated increased length of stay and risk of mortality. Potentially modifiable risk factors for AKI including medications were identified for all stratified age groups.
Collapse
Affiliation(s)
- Dana Y Fuhrman
- Children's Hospital of Pittsburgh, 4401 Penn Avenue, Children's Hospital Drive, Faculty Pavilion Suite 2000, Pittsburgh, PA, 15224, USA.
| | - Sandra Kane-Gill
- School of Pharmacy, University of Pittsburgh, 638 Salk Hall, 3501 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Priyanka Priyanka
- The Center for Critical Care Nephrology, 3347 Forbes Avenue, Ste 220, Pittsburgh, PA, 15213, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, 3347 Forbes Avenue, Ste 220, Pittsburgh, PA, 15213, USA
| |
Collapse
|
199
|
Sethi SK, Raghunathan V, Shah S, Dhaliwal M, Jha P, Kumar M, Paluri S, Bansal S, Mhanna MJ, Raina R. Fluid Overload and Renal Angina Index at Admission Are Associated With Worse Outcomes in Critically Ill Children. Front Pediatr 2018; 6:118. [PMID: 29765932 PMCID: PMC5938374 DOI: 10.3389/fped.2018.00118] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 04/12/2018] [Indexed: 11/20/2022] Open
Abstract
Objectives: We investigated the association of fluid overload and oxygenation in critically sick children, and their correlation with various outcomes (duration of ventilation, ICU stay, and mortality). We also assessed whether renal angina index (RAI) at admission can predict mortality or acute kidney injury (AKI) on day 3 after admission. Design and setting: Prospective study, pediatric intensive care in a tertiary hospital. Duration: June 2013-June 2014. Patients: Patients were included if they needed invasive mechanical ventilation for >24 h and had an indwelling arterial catheter. Patients with congenital heart disease or those who received renal replacement therapy (RRT) were excluded. Methods: Oxygenation index, fluid overload percent (daily, cumulative), RAI at admission and pediatric logistic organ dysfunction (PELOD) score were obtained in all critically ill children. KDIGO classification was used to define AKI, using both creatinine and urine output criteria. Admission data for determination of RAI included the use of vasopressors, invasive mechanical ventilation, percent fluid overload, and change in kidney function (estimated creatinine clearance). Univariable and multivariable approaches were used to assess the relations between fluid overload, oxygenation index and clinical outcomes. An RAI cutoff >8 was used to predict AKI on day 3 of admission and mortality. Results: One hundred and two patients were recruited. Fluid overload predicted oxygenation index in all patients, independent of age, gender and PELOD score (p < 0.05). Fluid overload was associated with longer duration of ventilation (p < 0.05), controlled for age, gender, and PELOD score. Day-3 AKI rates were higher in patients with a RAI of 8 or more, and higher areas under the RAI curve had better prediction rates for Day-3 AKI. An RAI <8 had high negative predictive values (80-95%) for Day-3 AKI. RAI was better than traditional markers of pediatric severity of illness (PELOD) score for prediction of AKI on day 3. Conclusions: This study emphasizes that positive fluid balance adversely affects intensive care in critically ill children. Further, the RAI prediction model may help optimize treatment and improve clinical prediction of AKI.
Collapse
Affiliation(s)
- Sidharth K Sethi
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Veena Raghunathan
- Pediatric Intensive Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Shilpi Shah
- Department of Pediatric Nephrology, Akron Children Hospital, Akron, OH, United States
| | - Maninder Dhaliwal
- Pediatric Intensive Care, Medanta, The Medicity Hospital, Gurgaon, India
| | - Pranaw Jha
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Maneesh Kumar
- Pediatric Intensive Care, Medanta, The Medicity Hospital, Gurgaon, India
| | | | - Shyam Bansal
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Maroun J Mhanna
- Department of Pediatrics, Metrohealth Medical Center, Cleveland, OH, United States
| | - Rupesh Raina
- Department of Pediatric Nephrology, Akron Children Hospital, Akron, OH, United States
| |
Collapse
|
200
|
Selewski DT, Goldstein SL. The role of fluid overload in the prediction of outcome in acute kidney injury. Pediatr Nephrol 2018; 33:13-24. [PMID: 27900473 DOI: 10.1007/s00467-016-3539-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 01/11/2023]
Abstract
Our understanding of the epidemiology and the impact of acute kidney injury (AKI) and fluid overload on outcomes has improved significantly over the past several decades. Fluid overload occurs commonly in critically ill children with and without associated AKI. Researchers in pediatric AKI have been at the forefront of describing the impact of fluid overload on outcomes in a variety of populations. A full understanding of this topic is important as fluid overload represents a potentially modifiable risk factor and a target for intervention. In this state-of-the-art review, we comprehensively describe the definition of fluid overload, the impact of fluid overload on kidney function, the impact of fluid overload on the diagnosis of AKI, the association of fluid overload with outcomes, the targeted therapy of fluid overload, and the impact of the timing of renal replacement therapy on outcomes.
Collapse
Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|